E NARRATIVE REVIEW ARTICLE Cardiac Arrest in the Operating Room: Part 2—Special Situations in the Perioperative Period Matthew D. McEvoy, MD, Karl-Christian Thies, MD, FRCA, FERC, DEAA, Sharon Einav, MD, Kurt Ruetzler, MD, Vivek K. Moitra, MD, FCCM, Mark E. Nunnally, MD, FCCM, Arna Banerjee, MD, Guy* Weinberg, MD, Andrea Gabrielli, MD, FCCM,† ‡ Gerald A. Maccioli,§ ∥MD, FCCM, Gregory Dobson,¶ MD, and Michael F. O’Connor,# MD, FCCM * ** †† ‡‡ §§ ∥∥ As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiol- ogy and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life- threatening causes of PPCA of which the management should be within the skill set of all anes- thesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid appli- cation of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the periop- erative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes. (Anesth Analg 2018;126:889–903) dvanced cardiac life support (ACLS) was originally developed as an extension of basic life support with Aa focus on out-of-hospital cardiac arrest (OHCA).1 From the Department of Anesthesiology, Vanderbilt University Medical Center, OHCA is now recognized as a distinct entity from in-hos- Nashville, Tennessee; Department of Anesthesiology, University Medical pital cardiac arrest (IHCA), particularly in relation to more Centre Greifswald,* Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany; Faculty of Medicine, †Shaare Zedek Medical Center, Hebrew University, common etiology of arrest, average response rescue time, Jerusalem, Israel; Departments of General Anesthesiology and Outcomes and survival.2 As noted previously,1 periprocedural cardiac Research,‡ Cleveland Clinic, Cleveland, Ohio; Department of Anesthesiology, Columbia University, College of Physicians§ and Surgeons, New ∥York, New arrest (PPCA) is different from both OHCA and medically York; Department of Anesthesiology, Perioperative¶ Care, and Pain Medicine, related IHCA. The etiologies of the crisis, the periopera- New York University, New York, New York; Department of Anesthesiology, tive team knowledge of the patient’s comorbidities, the The University# of Illinois at Chicago, Chicago, Illinois; University of Pennsylvania, Philadelphia, Pennsylvania; **Department of Anesthesiology awareness of current physiological state, and the immedi- and Critical Care, Sheridan Healthcare, Florida; Department†† of Anesthesia, ate rescue response time significantly improve restoration Dalhousie University, Halifax, Nova Scotia,‡ ‡Canada; and Department of Anesthesia and Critical Care, University of Chicago,§§ Chicago, Illinois. of spontaneous circulation and survival to discharge when ∥∥ 3–6 Accepted for publication September 8, 2017. compared to other forms of IHCA. K.-C. Thies is currently affiliated with the Department of Anesthesiology, In addition to these differences in clinical presentation University Medical Center Greifswald, Ferdinand-Sauerbruch-Straße, and management, numerous studies have also demonstrated Greifswald, Germany. knowledge and skill deficiencies in the proper assessment Funding: This review was developed from previous iterations on behalf of and management of perioperative crises within the anesthe- the American Society of Anesthesiologists and the Society of Critical Care 7–12 Anesthesiologists. Portions of those documents appear verbatim and are siology community. Frequent and concise updates of the used with the permission of the ASA. knowledge content necessary for managing high-stakes peri- Conflicts of Interest: See Disclosures at the end of the article. operative events is necessary for preparing anesthesiologists Listen to this Article of the Month podcast and more from OpenAnesthesia.org® and perioperative teams to provide appropriate and timely by visiting http://journals.lww.com/anesthesia-analgesia/pages/default.aspx. care.13,14 As noted in part 1, while previous publications have Implication statement: The spectrum of causes of periprocedural cardiac arrest warrants specific adaptations of the advanced circulatory life support algo- described cardiac arrest and crisis management in the oper- rithms. A number of rare, life-threatening etiologies of profound hemodynamic ating room, the most recent update in ACLS prompted a part and respiratory disturbance leading to cardiac arrest are reviewed. Good patient 1 review of the current literature concerning perioperative outcomes in these special situations can be achieved by vigilance, timely formu- lation of a differential diagnosis for the crisis, and adherence to best practices. life-threatening crisis and cardiac arrest. Accordingly, the Reprints will not be available from the authors. goal of this part 2 review is to offer an updated clinical per- Address correspondence to Matthew D. McEvoy, MD, Department of spective of cardiac arrest during the perioperative period. In Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center part 1, we summarize the causes and outcomes of periop- Dr, TVC 4648, Nashville, TN 37232. Address e-mail to matthew.d.mcevoy@ vanderbilt.edu. erative cardiac arrest, review concepts in resuscitation of the Copyright © 2017 International Anesthesia Research Society perioperative patient, and propose a set of algorithms to aid DOI: 10.1213/ANE.0000000000002595 in the prevention and management of cardiac arrest during March 2018 • Volume 126 • Number 3 www.anesthesia-analgesia.org 889 Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E NARRATIVE REVIEW ARTICLE the perioperative period. In this article, we discuss special typically complicated in the periprocedural and hospital anesthesia-related crises and the management thereof. setting, where patients are commonly exposed to multiple This review is focused on 8 special circumstances in the agents. Furthermore, anaphylactic reactions may occur with perioperative period that, while uncommon, are essential no documented prior exposure.19 Hypersensitivity reactions for all practicing anesthesiologists to know. The clinical sce- are graded 1–5 corresponding to minor, low severity, life- narios presented are severe anaphylaxis, tension pneumo- threatening symptoms, cardiac or respiratory arrest, and thorax, local anesthetic systemic toxicity (LAST), malignant death.20,21 The overall incidence of hypersensitivity reactions hyperthermia (MH), severe hyperkalemia, hypertensive crisis, is about 15 cases per 10,000 operations (95% confidence trauma-related cardiac arrest, and pulmonary embolism (PE; interval, 13–17 per 10,000).22 The incidence of severe thrombus or gas). Each scenario will be presented with a brief hypersensitivity reactions (grade 3–5) with life-threatening review of pathophysiology and epidemiology followed by rec- symptoms is about 2 cases per 10,000 operations.22 ommendations on proper assessment, initial management, and subsequent management of each perioperative crisis based Presentation and Initial Assessment. Anaphylaxis on a comprehensive review of the literature. The information is characterized by the rapid onset of potentially life- presented in this article represents the background behind the threatening airway, breathing, or circulatory problems. management recommendations proposed in widely available The initial symptoms are nonspecific. Rhinitis, tachycardia, crisis management checklists such as the Stanford and Harvard confusion, altered mental status/presyncope, and skin crisis checklists that are familiar to many practicing anesthesi- and mucosal changes are common in the awake patient, ologists.15,16 It should be noted that these well-recognized clini- but not always present.23 In addition, bronchospasm is cal entities are presented as single cause of a life-threatening not present in all cases and does not necessarily precede crisis and out of the clinical contest of more complex condition cardiovascular instability. Extensive vasodilatation and like septic shock or multiorgan system failure. increased vascular permeability lead to decreased cardiac preload with relative hypovolemia, which can in turn METHODS cause cardiovascular depression, myocardial ischemia, An international group of 12 experts in the field of periop- acute myocardial infarction, and malignant arrhythmias erative resuscitation